Previous work suggests that safety culture plays an important role in improving patient safety. Traditional training modalities can raise consciousness about safety culture issues, but do not provide the practice needed to truly inculcate and sustain them. In contrast, simulation training is immersive and clinically engaging, and thus is believed to have a stronger and more lasting effect than traditional teaching methods. This project will investigate whether rural/community hospitals and academic/urban hospitals can adopt a long-term simulation strategy, what obstacles must be overcome to achieve adoption, how successfully the programs can target teamwork and safety culture, and what impact the programs have on the work units that implement them. The four overarching goals of this project are: (1) To articulate more fully the direct and indirect linkages between simulation activities and safety culture; (2) To facilitate the adoption of simulation as a culture change strategy in diverse hospitals; (3) To develop simulation scenarios and exercises for clinical teams that probe and challenge the culture of safety, using facilitated debriefing to emphasize learning about culture and to foster behavioral change; (4) To assess the process and amount of culture change achieved to determine the generalizability of this intervention strategy. To achieve these goals, we have the following specific aims: Aim 1: To build on existing work to create simulation activities that explicitly address important aspects of safety culture and that can be implemented using "in-situ" simulation in actual work units of 3 client hospitals: 2 rural/community and 1 urban/academic. We will modify and customize proven simulation scenarios and facilitated debriefer teaching techniques to emphasize evidence-based safety culture issues on the basis of initial hospital needs assessments. Aim 2: To pilot test these activities in the 3 client hospitals working with multidisciplinary teams from several high-hazard units (e.g., ICU, medical emergency, rapid response/code, emergency department) in each institution. The pilot test will include an intensive instructor training course and ongoing mentorship through remote consultation and site visits. Aim 3: To evaluate the results of the pilot tests to learn about the effectiveness of the new simulation activities and their impact on aspects of safety culture. We will examine the impact of simulation on safety culture by surveying personnel in participating and non-intervention work units and comparing changes in their perceptions of safety culture before and after the simulation intervention. We will also use multiple methods, including process measures and participant evaluations, to evaluate simulation qualitatively. [unreadable] [unreadable] [unreadable]